Provider Demographics
NPI:1730356452
Name:HORNBECK, MICHAEL
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:HORNBECK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 BROADWAY MALL
Mailing Address - Street 2:
Mailing Address - City:HORNELL
Mailing Address - State:NY
Mailing Address - Zip Code:14843-1920
Mailing Address - Country:US
Mailing Address - Phone:607-324-4822
Mailing Address - Fax:
Practice Address - Street 1:34 BROADWAY MALL
Practice Address - Street 2:
Practice Address - City:HORNELL
Practice Address - State:NY
Practice Address - Zip Code:14843-1920
Practice Address - Country:US
Practice Address - Phone:607-324-4822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-12
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006738-1156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01624708Medicaid